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WELL ERMIT APPLICATION F_ <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br /> <br />SITE <br />MITIGATION <br />fl1 L <br />SEP 2 6 2003 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT HEALTH pplication is hereby made to San Joaquin County for a permit to consMict and/or install the work described. This application is rrigklimirsiffmattd3 San <br />oaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department.' I <br />/ELL Location <br />A(')C4L Address e. 0, 61K 1 0 *V19 City WitZip - <br />-57 Contractor 11\ CS) Cityayja0bzip _ic# 65Fechone# 69,09)C-Ko7-1(ja Address <br />ac09 a<1 f\.) LOQ-Of16814ttreet 17OJ 1ç1nJL., City -t-z3d(-:PA Zip 9 4/ WO Parc.eli <br />Assessor <br />ROPERTY Owner Phone# <br />tt (..) City Lic# ft Phone# Jr onsultant / Sub Cntr Address <br />IS Coordinates: X , Township Range Section <br />ORK TO BE PERFORMED: <br />NEW WELL I BORING (CPT, GEOPROBE, HYDROPaNCH, HAND-AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />ASOIL BORING # wr T a OVER-BORE fl WELL # 0 PRESSURE GROUT <br />tther. Grout Specifications: <br />OWEN-1-S <br />'PE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING I] HOLLOW STEM DIA. OF BOREHOLE] DS" MULTIPLE CASINGS? a MULTI-LEVEL? a WELL CASING DIA: <br />EXTRACTION AIR HAMMERJDRIVEN CASING THICKNESS A L TYPE OF CASING: STEEL PVC a OTHER: <br />VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS fl HOSE <br />JR SPARGE 1 ozone a PUSH POINT GROUT SEAL PUMPED: 11 Yes No (N TE: 1AXIMUM FREE-FALL DEPTH IS 30') <br />SOIL BORING <br />DTHER: <br />OMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />lereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />)unty Or "nances, Rules and Regulations, and all applicable California State ws. <br />Tied x Title/Company &.,44; 'leo/ f <br />I <br />DEPARTMENT USE ONLY <br />TE MAP IN UNIT IV FILE, ADDRESS: Z- S-0 / <br />ORK PLAN DATED: )0 IIG; 103 <br />olication Accepted By Date Issued / I/O.)) Area <br />)ut Inspection ByLASAA64,ar44:,_Date Final Inspection By-titAC Date IGH03 <br />struction Inspection By <br />1.A <br />U HAND AUGER <br />11 OTHER <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />(D/ I] BOLTED TRAFFIC BOX or a STOVE PIPE <br />nt Name Date 9(.7 -03 <br />Date <br />MMENTS I CONDMONS: <br />CCOUNT1NG ONLY: AID# <br />_ <br />' <br />E CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT i SERVICE REQUEST # INVOICE <br />1,41C2A --$[ O. &'. 112-9 S'' (4 10 % 0) 3 5-gig Y . <br />57 WC -WAIVER C-57 Letter of Authorization to sign permit <br /> <br />Encroachment doc 8/29/02 <br />